1548367014 NPI number — MR. MATTHEW JOSEPH TISBY M. DIV.

Table of content: MR. MATTHEW JOSEPH TISBY M. DIV. (NPI 1548367014)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548367014 NPI number — MR. MATTHEW JOSEPH TISBY M. DIV.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TISBY
Provider First Name:
MATTHEW
Provider Middle Name:
JOSEPH
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
M. DIV.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548367014
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2437 ROY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHREVEPORT
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-424-9584
Provider Business Mailing Address Fax Number:
318-424-6121

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2437 ROY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-424-9584
Provider Business Practice Location Address Fax Number:
318-424-6121
Provider Enumeration Date:
09/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP1600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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